Summary
Dr. Owen Muir, founder of Fermata Health in Brooklyn and one of the leading TMS practitioners in the country, provides a comprehensive overview of transcranial magnetic stimulation. He traces the history from Arthur Sackler's influence on psychiatric drug marketing to the shift toward neuromodulation, explaining TMS as an external pacemaker for feelings that uses Faraday's law to induce electrical currents in targeted brain regions. Muir presents striking data showing accelerated TMS achieves 79% remission rates for depression and discusses the SAINT protocol's use of spaced learning theory to optimize treatment. He also covers TMS for OCD (31% remission), bipolar disorder considerations, and the profound life changes patients experience when depression fully remits rather than merely improving 50%.
Key Points
- TMS uses changing magnetic fields to induce electrical currents in the brain, functioning as an external pacemaker for feelings
- Accelerated TMS achieves 79% remission for depression versus 50% symptom reduction typical of medications
- The SAINT protocol uses fMRI-guided targeting of the anti-correlated subgenual cingulate region for precise treatment
- Spaced learning theory underlies the accelerated approach: 10 sessions per day with intervals mirrors optimal memory consolidation
- Getting targeting right matters about 30% in terms of outcomes, making fMRI guidance clinically significant
- TMS for OCD achieves about 31% full remission targeting a different brain region
- Patients may experience life-changing shifts after remission, and providers should warn about potential relationship changes
- Insurance does not yet cover accelerated TMS protocols despite superior outcomes
Key Moments
TMS explained as an external pacemaker for feelings
Dr. Muir offers an elegant explanation of TMS as an external pacemaker for emotions, using magnetism to induce electrical currents that resynchronize brain rhythms.
"TMS transcranial, aka going across the cranium into the brain harmlessly, magnetic, using magnetism stimulation, is basically an external pacemaker for your feelings."
Accelerated TMS achieves 79-90% remission rates
Dr. Muir presents the clinical data showing accelerated TMS with the SAINT protocol achieves 79% remission for depression using 10 daily stimulations over five days, a fundamentally different outcome than medication-based approaches.
"That was the approach in that study. Yeah. Without any, any drugs at all. The, the, the saint trial and, and, uh, other, other papers on that topic on accelerated TMS, uh, use 10 stimulations in a day and did it over five days in a row. And we're getting remission in 79% of people at the end of a month. Um, 60, 60% are in remission. Their depression is over at the end of day five. And like,"
Warning about life changes after TMS remission
Dr. Muir discusses the consent challenges unique to TMS, including warning patients that full remission from depression can trigger major life decisions like divorce, because the experience is so fundamentally different from 50% symptom reduction.
"I warn people getting accelerated TMS that we've seen people get a divorce after this treatment. Now, it turns out a lot of people who are depressed and have been depressed for a long time will get better and realize they're not happy with their life."
TMS for OCD achieves 31% remission
Dr. Muir discusses TMS outcomes for OCD, noting a 31% full remission rate and that personality disorders do not predict non-response to treatment.
"We have remission in OCD on the order of 31%, but full remission is less likely than it is in depression."
